Question 1

A client who recently had surgery is medicated prior to return to the nursing unit.Which assessment finding warrants the need for a more in-depth assessment when determining the client's score on the sedation scale?

Accepted Answer

A client who is somnolent with minimal or no response to physical stimulation may indicate excessive sedation and potential respiratory depression. This warrants a more in-depth assessment to ensure client safety. The other options are within normal limits for sedation scales.

Question 2

The nurse documents the assessment and interventions performed to relieve the client's pain on a pain management flow sheet.Why is this documentation important?

Accepted Answer

The answer of The nurse documents the assessment and interventions...

Question 3

The nurse is initiating a client-controlled anesthesia (PCA)pump delivering morphine sulfate for an older school-age client post-appendectomy.Prior to connecting the PCA tubing to the client's IV fluid line,which action by the nurse is the priority?

Accepted Answer

The answer of The nurse is initiating a client-controlled anesthesia...

Question 4

The nurse is instructing the client on how to use the client-controlled analgesia (PCA)pump.Which statement made by the client indicates an appropriate understanding of the nurse's instructions regarding the use of the PCA pump?

Accepted Answer

The client should push the button when the pain becomes severe. It is important to use the PCA pump as directed by healthcare providers and not allow others to control the medication. Continuously pushing the button may result in an overdose of pain medication.

Question 5

After administering an opioid analgesic,the nurse assesses the client using the sedation scale and finds the client sleeping and arousable,but the client drifts off to sleep during conversation.Which level of sedation is appropriate for the nurse to document for this client in the medical record?

Accepted Answer

The client's sedation level is at level 3 (moderate sedation). The client is able to speak but may be drowsy and drifts off to sleep during conversation. The nurse should monitor the client closely to ensure the client does not progress to deeper levels of sedation or respiratory depression.

Question 6

Which can the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Providing a massage and repositioning the client in pain can be safely delegated to the UAP as long as the nurse has provided appropriate instruction and supervision. The other tasks require a licensed nurse to perform them.

Question 7

Nurses must be aware of cultural considerations when assisting clients with pain tolerance.Which statement made by the nurse indicates an understanding of cultural awareness?

Accepted Answer

Option D correctly states that nurses must have an understanding that different cultures have different ways of dealing with pain. This requires the nurse to be culturally sensitive and not judge clients based on any misconceptions of pain and its treatment. Options A, B, and C are incorrect as they either generalize pain experiences across cultures or ignore cultural differences.

Question 8

Pain is a complex phenomenon that affects both the physical and mental areas.When teaching the client about pain,which statement made by the client would indicate appropriate understanding?

Accepted Answer

Option B correctly defines acute pain as a type of pain that is sudden and varies in intensity. Option A is incorrect because cancer pain can be acute or chronic and can last for an extended period. Option C is partially correct because chronic pain can be acute, chronic, or intermittent, but the statement as a whole lacks clarity. Option D is entirely incorrect because chronic pain is defined as lasting for more than three months.

Question 9

The client reports difficulty sleeping related to anxiety.Which nonpharmacologic pain management intervention might the nurse consider performing in order to relax the client?

Accepted Answer

Massage has been shown to promote relaxation and reduce anxiety, which may improve the client's ability to sleep. Acupuncture and acupressure may also be effective, but these interventions typically require the assistance of a trained practitioner. Distraction techniques may not directly address the client's anxiety and may not be as effective as relaxation techniques.

Question 10

The nurse is administering a back massage to the client.Place the steps in the proper order of performance.

Accepted Answer

The proper order of performing a back massage is to first move your hands up the center of the back (B), then massage both scapulae (D), followed by massaging the sacral area using smooth, circular strokes (C), then massage the areas over the right and left iliac crests (A), and finally move your hands down the side of the back (E). This sequence allows for a smooth and effective massage that promotes relaxation and relieves tension.

Question 11

The nurse is assessing a client's chronic pain.The client indicates the pain is in the upper right quadrant of the abdomen,rates the pain as a 9 on a 1-10 scale,and describes the pain as sharp and continuous.What else would the nurse assess regarding this client's pain?

Accepted Answer

The nurse should assess the onset, duration, and recurrence of the pain to gather comprehensive information about the client's chronic pain experience.

Question 12

The postoperative client has been noting a steady decline in the amount of pain experienced over the past week.Today,upon awakening,the pain is far more severe even at rest.Which priority intervention should the nurse perform for this client?

Accepted Answer

A sudden increase in pain after a period of improvement may indicate a complication or an issue that needs medical attention. The nurse should assess the client fully to identify the cause of the pain increase and notify the healthcare provider as soon as possible. Administering stronger opioids without identifying the underlying cause of the pain increase can be dangerous and may mask the symptoms of a serious condition. Explaining or assuming that the pain increase is due to the client's increased activity level is not appropriate without further assessment.

Question 13

The nurse administered an oral analgesic to a client complaining of a mild-to-moderate headache.Which activity would the nurse consider to help relieve the client's discomfort until the analgesic takes effect?

Accepted Answer

Slow rhythmic breathing can help the client relax and ease the discomfort of a headache until the analgesic takes effect. Reading, watching TV, playing video games, or doing crossword puzzles may actually exacerbate the headache.

Question 14

The unlicensed assistive personnel (UAP)informs the nurse that the client is complaining of severe postoperative pain and requests pain medication.Which action would be appropriate for the nurse to perform?

Accepted Answer

As the registered nurse, it is the nurse's responsibility to assess the client's pain and respond appropriately based on nursing judgement and medication order protocol. Asking for more data from the UAP may be helpful in determining the severity and characteristics of the pain, but ultimately, the nurse should directly assess the client before administering any medication. Option A would be appropriate if and when the nurse determines that medication is necessary. Option D is not appropriate as it delays the nurse's response to the client's needs.

Question 15

The nurse is teaching progressive muscle relaxation techniques to the client.Which rationale will the nurse include in the teaching session for progressive muscle relaxation?

Accepted Answer

Progressive muscle relaxation is a technique that involves tensing and then relaxing different muscle groups to reduce muscle tension and promote relaxation. By releasing muscle tension, the negative effects of stress on the body can be lessened, including physical symptoms such as headaches, muscle pain, and fatigue. It is not a form of diversion or exercise, and it may not necessarily alleviate pain that is caused by other underlying medical conditions.

Question 16

Many clients have misconceptions regarding assessment and treatment of pain.Which statement by the client indicates the need for additional clarification?

Accepted Answer

The client's statement that the best judge of the existence and severity of pain is the nurse who is taking care of them is a misconception. Pain is a subjective experience, and the best judge of pain is the person experiencing it. Nurses may assess pain and use that information to guide treatment, but they cannot accurately determine the existence or severity of someone else's pain. The other three statements are accurate and do not indicate a need for clarification.

Question 17

The nurse is applying a TENS unit to a client in pain.Prior to applying the electrodes,which action by the nurse is the most appropriate?

Accepted Answer

Before applying the electrodes, the nurse should wash, rinse, and dry the designated area with soap and water to ensure the skin is clean and free of oils, lotions, or other substances that could interfere with the electrical current. Turning the unit on, increasing the amplitude, or changing the battery can wait until after the electrodes are properly placed on the client's skin.

Question 18

The nurse is assisting the client with the use of guided imagery.Which action by the nurse is the most appropriate when initiating guided imagery?

Accepted Answer

Asking the client to take slow, full diaphragmatic/abdominal breaths is the most appropriate action when initiating guided imagery. This will help the client to relax and become more receptive to the guided visualization.

Quiz 9: Pain Management